Healthcare Provider Details

I. General information

NPI: 1316015647
Provider Name (Legal Business Name): CAROLYN J. HENDERSON L.I.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MINNI TOHE DR MINNE TOHE HEALTH CENTER
NEW TOWN ND
58763-4400
US

IV. Provider business mailing address

1 MINNI TOHE DR MINNE TOHE HEALTH CENTER
NEW TOWN ND
58763-4400
US

V. Phone/Fax

Practice location:
  • Phone: 701-627-4701
  • Fax: 701-627-2810
Mailing address:
  • Phone: 701-627-4701
  • Fax: 701-627-2810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3253
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: